Adolescent Health, Medicine and Therapeutics
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Family-based treatment of eating disorders in
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adolescents: current insights
Renee D Rienecke 1–3
1
Department of Pediatrics,
2
Department of Psychiatry and
Behavioral Sciences, College of
Medicine, Medical University of
For personal use only.
South Carolina, Charleston, SC,
3
Department of Psychiatry, University
of Michigan Health System, Ann Arbor,
MI, USA
Correspondence: Renee D Rienecke
Medical University of South Carolina, 261
Calhoun Street – 220, Charleston, SC
29401, USA
Tel +1 843 792 8157
Fax +1 843 876 8462
Email rienecke@musc.edu
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http://dx.doi.org/10.2147/AHMT.S115775
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Abstract: Eating disorders are serious illnesses associated with significant morbidity and mortal-
ity. Family-based treatment (FBT) has emerged as an effective intervention for adolescents with
anorexia nervosa, and preliminary evidence suggests that it may be efficacious in the treatment
of adolescents with bulimia nervosa. Multifamily therapy for anorexia nervosa provides a more
intensive experience for families needing additional support. This review outlines the three
phases of treatment, key tenets of family-based treatment, and empirical support for FBT. In
addition, FBT in higher levels of care is described, as well as challenges in the implementation
of FBT and recent adaptations to FBT, including offering additional support to eating-disorder
caregivers. Future research is needed to identify families for whom FBT does not work, determine
adaptations to FBT that may increase its efficacy, develop ways to improve treatment adherence
among clinicians, and find ways to support caregivers better during treatment.
Keywords: eating disorders, adolescents, family-based therapy, anorexia nervosa, bulimia
nervosa
Introduction
Eating disorders are serious psychiatric illnesses that generally develop during adoles-
cence, and are associated with significant medical and psychological sequelae. Anorexia
nervosa (AN) is characterized by significantly low body weight, fear of weight gain
or behavior that interferes with weight gain, and disturbance in the way one’s body
weight or shape is experienced, overvaluation of shape and weight, or lack of recogni-
tion of the seriousness of the low body weight. Lifetime prevalence rates of AN and
subthreshold AN among adolescents are 0.3%–0.6% and 0.6%–0.8%, respectively.1,2
High rates of comorbidity are found among patients with AN, with approximately 50%
meeting criteria for another psychiatric disorder.2,3 AN is associated with impaired
quality of life4 and significantly elevated mortality rates that are among the highest of
any psychiatric illness.5,6
Bulimia nervosa (BN) is characterized by recurrent episodes of eating that are
accompanied by a sense of loss of control, as well as inappropriate compensatory
behavior and overvaluation of shape and weight.7 Lifetime prevalence rates of BN and
subthreshold BN among adolescents are 0.9% and 6.1%, respectively.1,2 Almost 90%
of patients with BN meet criteria for another co-occurring psychiatric disorder,2 and
BN is associated with high rates of impairment and suicidality. Binge-eating disorder
is characterized by binge-eating episodes that are not accompanied by inappropriate
compensatory behavior, but are associated with marked distress. Prevalence rates for
binge-eating disorder are 1.6% among adolescents.2 Avoidant/restrictive food-intake
Adolescent Health, Medicine and Therapeutics 2017:8 69–79 69
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 Rienecke
disorder (ARFID), introduced as a new disorder in the fifth
edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5),7 is characterized by an eating or feeding
disturbance resulting in significant weight loss or failure to
achieve expected weight, nutritional deficiencies, dependence
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on enteral feeding or nutritional supplements, or interference
with psychosocial functioning. Prevalence estimates range
from 5%8 to 22.5%,9 depending on the treatment setting.
A substantial number of individuals experience clinically
significant difficulties with eating that do not meet criteria
for one of the aforementioned diagnoses.2,10,11 A diagnosis of
other specified feeding or eating disorder is given in these
cases. Despite the subthreshold nature of this diagnosis,
patients who do not meet full criteria for an eating disorder
are still medically compromised11 and often do not differ in
clinically significant ways from their full-threshold counter-
parts.12,13 Approximately 13% of adolescents will develop
an eating disorder by the age of 20.14 Eating disorders have
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been reported to be the third-most common chronic condition
among adolescents, behind obesity and asthma.15
Family-based treatment for AN
Research on the treatment of eating disorders in adolescents
has lagged behind that of adults, but family-based treatment
(FBT), also sometimes known as the Maudsley method or
Maudsley approach, has emerged as an effective intervention
and is considered by some to be the treatment of choice for
adolescents with AN who are medically stable and fit for
outpatient treatment. FBT is a manualized outpatient therapy
designed to restore adolescents to health with the support
of their parents.16 The treatment for AN consists of three
phases. Phase 1 focuses on the rapid restoration of physical
health, orchestrated by parents. It is explained to families that
because of the ego-syntonic nature of the disorder, the patient
on his or her own will have difficulty making healthy deci-
sions about food and eating. In an effort to keep patients out
of higher levels of care, decisions about eating are temporar-
ily taken out of their hands and given to parents. Parents are
given responsibility for deciding what their child eats, how
much is eaten, when it is eaten, monitoring all food intake,
and generally curtailing physical activity, much like the treat-
ment team would do on an inpatient unit. The goal of FBT,
however, is to allow patients to recover in their day-to-day
environment with their support system around them, rather
than separating them from their parents by sending them to
an inpatient or residential treatment program. Siblings are
given a supportive role in treatment, and are not included in
the parents’ job of weight restoration.
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The second session of FBT consists of a family meal,
in which the family brings a meal into the therapist’s office
and the therapist begins to instruct the family in ways to be
more effective with both the eating disorder and their child.
The purpose of the family meal is to give parents, who at this
point are often feeling quite defeated by the eating disorder,
a taste of success in encouraging their child to eat more than
he or she had originally intended.
Phase 1 continues until there is steady weight gain, the
eating disorder has begun to recede, and the child is eating
without much resistance to parental involvement. Phase 2
involves gradually giving responsibility over eating back
to the adolescent, to whatever extent is age-appropriate
and normal for a particular family. This phase is conducted
gradually, in order to minimize the chances of backsliding,
which can be disheartening to families and therapists alike.
For example, rather than having parents serve a child at dinner
as they would during phase 1, the child may begin to serve
himself or herself, with parental oversight in place and the
understanding that parents will add food if they deem what
the child chose to be inadequate.
In Phase 3, there is a review of adolescent development,
and the therapist ensures that the family is back on track with
normal family life. The family identifies upcoming develop-
mental challenges that the adolescent must face, and identi-
fies how to help the young person navigate these challenges
without reverting to the eating disorder as a way to cope.
Family-based treatment for BN
FBT has been adapted for use with patients with BN.17
Although it shares several similarities with FBT-AN, the main
focus of FBT-BN is on interrupting the pattern of binge eating
and purging. Although parents are still in charge of recovery,
the approach tends to be more collaborative in nature. This
is possible in part because of the more ego-dystonic nature
of the illness when compared to AN. Care is taken to modify
parental criticism, which may be higher in families of a patient
with BN than with AN,18 and to reduce the shame and secrecy
commonly surrounding binge-eating and purging behaviors.
In addition, there is somewhat more flexibility in the approach,
allowing for a shift in focus to address comorbid illnesses or
behavioral problems that may present themselves more often
than is usually the case in the treatment of AN.
Family-based treatment for other
eating and weight disorders
FBT has also been adapted for use with prodromal presen-
tations of AN,19 pediatric obesity (PO),20 and ARFID.21 In
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comparison to FBT-AN, the emphasis in FBT for prodromal
AN shifts from rigorous weight restoration to normalization
of eating habits and efforts to prevent the development of
full-blown AN.19 There is also a focus on implementation
of regular family meals and modeling of healthy eating by
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parents.
In FBT-PO, treatment approaches are modified accord-
ing to the age of the patient.20 Parents are involved at the
beginning of treatment to varying degrees, depending on
whether the patient is a child, preadolescent, or adolescent,
and parental control over eating and exercise lessens over
the course of treatment. For children in FBT-PO, parental
involvement at the beginning of treatment may look very
similar to FBT-AN, in that parents take full responsibility
for all eating-related decisions and monitor all meals and
snacks. However, in FBT-PO, parents would also initiate
physical activity.
In FBT-ARFID, the focus of treatment is on helping
For personal use only.
parents increase the types and variety of food consumed by
the patient.21 There is an emphasis on educating the parents
about the factors unique to ARFID, such as the mechanisms
that keep children from trying new foods and the frequency
with which new foods need to be presented. These adaptations
to FBT appear promising, but data are needed to determine
the efficacy of FBT for different populations.
Key tenets of family-based
treatment
There are several key tenets of FBT that are important to keep
in mind when working with families. These tenets set FBT
apart from many other schools of thought when it comes to
treating eating disorders. First, FBT takes an agnostic view of
the cause of the illness, ie, no assumptions are made about the
potential causes of eating disorders.16 Instead, they are viewed
as complex and multifactorial illnesses, with many different
critical factors needing to “fall into place” for an eating disor-
der to develop. The focus of FBT is not on identifying these
various factors, but on identifying what needs to be done to
help the adolescent move forward with recovery as quickly
as possible. The adolescent is not blamed for developing the
illness, while it is also made clear to families that parents are
not to blame for causing the illness.
Second, there is a focus on externalizing the illness from
the patient. It is emphasized that the eating disorder and
the child are not one and the same. The eating disorder has
“taken over” the child when it comes to issues of food, eat-
ing, shape, and weight, and in those instances it is driving
the child’s thoughts, feelings, and behaviors. Parents must
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Family-based treatment of eating disorders
know that their child is not in control of the disorder, and just
as they did not choose to develop the disorder, they cannot
choose to stop the eating-disordered behavior. Externalization
serves several purposes, one of which is to reduce parental
criticism, which has been shown to have a negative impact
on treatment outcome.22–26
A third tenet is that the therapist takes a nonauthoritar-
ian therapeutic stance when working with the family. The
therapist takes an active role in guiding the family through
the recovery process, but does not tell the family exactly how
to go about helping their child recover. Rather, the therapist
joins the family in helping them figure out for themselves
the best way to refeed their child. There is no one-size-fits-all
approach in FBT. Families are told that they are in charge
of weight restoration, but they are not given an exact plan
for how to accomplish this. While the therapist is seen as an
expert consultant, the parents are seen as the experts on their
family, with knowledge about the family’s likes, dislikes,
habits and routines, preferences, and ethnic, religious, and
cultural backgrounds, all things that can impact a family’s
eating patterns. Therefore, they are in the best position to
come up with a plan for helping their child recover.
Empowerment of the parents is another tenet of the treat-
ment approach. In FBT, parents are in no way thought to be
responsible for causing the eating disorder.27 Rather, FBT
views parents as their child’s best resource for recovery and
the main agents of change in the therapeutic process. To be
successful in overcoming the eating disorder, parents must
feel confident in their interactions with their child and with
the eating disorder. The therapist works to empower parents
by putting them in charge of the process and communicat-
ing to them that the therapist has confidence in their ability
to beat the eating disorder. Parents are reminded that they
do know how to feed their child, but that the eating disorder
has caused them to doubt themselves. By not providing the
parents with specific meal plans or explicit instructions on
how to bring about recovery, the parents must figure out what
will work best for them. This in turn allows them to rely
largely on themselves more than the therapist or treatment
team, thus building confidence.
Finally, FBT is a very pragmatic approach with an
unwavering initial focus on symptom reduction. In an effort
to reduce any potential long-term damage that can be done by
the state of malnutrition, there is an emphasis on interrupting
the pattern of restricting and quickly restoring the patient to
physical health. Problems associated with the eating disorder,
such as depressed mood, anxiety, irritability, difficulty con-
centrating, or social withdrawal, are not addressed directly in
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the first phase of FBT. This is in part to ensure that the focus
remains on weight restoration, and in part because many of
these secondary problems will resolve themselves with the
return to physical health.28
Empirical evidence for family-based
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treatment for AN
The first randomized controlled trial (RCT) for adolescent
AN was conducted by Russell et al at Maudsley Hospital
in London.29 Eighty female patients with eating disorders
between the ages of 14 and 55 years were admitted to an
inpatient unit for weight restoration, and upon discharge
were randomized to 1 year of family therapy or individual
therapy. Due to the heterogeneity in age and diagnosis,
participants were divided into four subgroups. One group
consisted of adolescents with AN who had a short duration
of illness, defined as less than 3 years, and an early age of
onset, defined as on or before the age of 18 years. Patients in
For personal use only.
this subgroup responded better to family therapy, with 90% of
patients falling into “good” or “intermediate” Morgan–Rus-
sell outcome categories (based on body weight, menstrua-
tion, and presence/absence of bulimic symptoms), whereas
only 18% of patients receiving individual therapy fell into
these categories. Furthermore, these gains were maintained
at 5-year follow-up.30
The first studies outside Maudsley Hospital were con-
ducted by Robin et al.31,32 They randomized 37 adolescents
with AN to either behavioral family systems therapy (BFST)
or ego-oriented individual therapy (EOIT). BFST was similar
to FBT, but also incorporated nutritional counseling and
cognitive restructuring. In EOIT, the therapist met with the
adolescent weekly and had bimonthly collateral sessions
with the parents. The focus of treatment was on building the
adolescent’s ego strength, developing coping skills, helping
to individuate from his or her family of origin, and explor-
ing other interpersonal issues and how they relate to eating.
Both groups gained weight, although the BFST group gained
more than the EOIT group at the end of treatment and 1-year
follow-up. At the end of treatment, more patients in BFST
than in EOIT had resumed menstruation. Few differences
were found between the two groups on measures of eating
attitudes, depression, ego functioning, and family relations.
A large RCT randomized 121 adolescents with AN to
either FBT or individual adolescent-focused therapy (AFT;
previously referred to as EOIT).31–33 The primary outcome
variable in this study was full remission, defined as reaching
at least 95% of expected body weight and achieving a mean
global score on the Eating Disorder Examination within
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one standard deviation of community norms. The authors
found no differences between the two groups at the end of
treatment, but significantly more patients receiving FBT had
achieved full remission at 6-month (FBT 40%, AFT 18%)
and 12-month (FBT 49%, AFT 23%) follow-up.
Various forms of FBT have also been studied. Because
patients in the Russell et al study29 were hospitalized for
weight restoration prior to beginning treatment, the study can
be conceptualized as a relapse-prevention study. Therefore,
efforts were made to examine the efficacy of FBT without
prior hospitalization of patients. Le Grange et al34 and Eisler
et al35 each compared two forms of family treatment among
adolescents with AN. In conjoint family therapy, the ado-
lescent and parents are seen together with the therapist. In
separated family therapy, the adolescent is seen alone by the
therapist and the parents are then seen separately. Le Grange
et al found no differences between the two treatment groups.
In a separate study of 40 adolescents with AN, Eisler et al
found that approximately 60% of patients fell into the Mor-
gan–Russell good- or intermediate-outcome categories, with
no significant differences between conjoint family therapy
and separated family therapy. Patients continued to improve
after treatment ended, with 90% of patients in the good or
intermediate categories at 5-year follow-up.24
Lock et al36 examined short- and long-term versions of
FBT. Eighty-six adolescents with AN were randomized to
short-term FBT (ten sessions over 6 months) or long-term
FBT (20 sessions over 12 months). No significant differences
were found at the end of treatment between the two groups.
However, nonintact families and patients with higher levels
of eating-related obsessive–compulsive symptoms did bet-
ter in the long-term version. Specifically, patients with high
levels of eating-related obsessive–compulsive symptoms
gained more weight in the long-term treatment, and patients
from nonintact families had lower global scores on the Eating
Disorder Examination if they participated in the long-term
treatment. Four years later, 83% of the 86 patients were fol-
lowed up, and no significant differences were found between
those receiving short- and long-term treatment; 89% of
patients had an expected body weight above 90%, and 90%
were menstruating. No moderators of maintenance of treat-
ment effects were found.37
Recently, Le Grange et al compared FBT to an adaptation
of FBT called parent-focused treatment (PFT).38 In PFT, the
adolescent is seen at the beginning of the session by a nurse
who weighs the patient, assesses medical stability, and pro-
vides brief supportive counseling. This information is then
shared with the therapist, who spends the rest of the session
Adolescent Health, Medicine and Therapeutics 2017:8
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meeting alone with the parents. A total of 107 patients with
AN were randomized to FBT or PFT. The primary outcome
variable was full remission, as defined in Lock et al.33 Remis-
sion rates were higher in PFT (43%) than in FBT (22%) at
the end of treatment, but the treatment groups did not differ
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at 6- or 12-month follow-up.
A question arising at this point is: does FBT work
because of the involvement of the parents, or is it the spe-
cific way in which parents are involved that leads to the
treatment’s efficacy? This was assessed by Agras et al39 in a
study comparing FBT to systemic family therapy (SFT). In
SFT, the focus of treatment is on the family system and on
the relationships and interactions that develop among family
members. Normalization of eating and weight is not a specific
focus of treatment, but is addressed if the family raises the
issue. The authors found no significant differences between
treatment groups in percentage expected body weight at the
end of treatment or 1-year follow-up. However, participants
For personal use only.
in FBT gained weight significantly faster than participants
in SFT, and significantly fewer participants in FBT were
hospitalized.
There is preliminary evidence to suggest that FBT is
effective for older populations in addition to adolescents.40,41
In a small study, 22 patients with AN between the ages of
18 and 26 years participated in a 6-month open trial of FBT
for young adults (FBT-Y).41 Patients started treatment at a
mean body mass index (BMI) of 17.84. At end of treatment
and 6-month follow-up, 68% had a BMI ≥19, and 59% had
a BMI ≥19 at 12-month follow-up. FBT-Y also resulted in
improvements in eating-disorder psychopathology, eating-
related obsessions and compulsions, other Axis I disorders,
and global functioning. However, dropout rates were 41%.
Empirical evidence for family-based
treatment for BN
Although BN generally develops during adolescence, only
three RCTs for adolescent BN have been published to date. Le
Grange et al42 randomized 80 adolescents to either FBT-BN
or individual supportive psychotherapy (SPT). The primary
outcome variable was abstinence from binge eating and purg-
ing over the previous 28 days. At the end of treatment, more
patients in FBT were abstinent (39%) than in SPT (18%),
and this difference remained significant at 6-month follow-up
(FBT 29%, SPT 10%). In addition, reduction in symptoms
occurred more rapidly for patients receiving FBT.
Schmidt et al43 compared family therapy to cognitive
behavioral therapy guided self-care (CBT-GSC) for 85 adoles-
cents. The family therapy in this study was similar to FBT-BN,
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but differed in that adolescents were allowed to choose “close
others” other than parents in their treatment, and a quarter of
patients chose this option. The primary outcome variable was
abstinence from binge eating and purging over the previous
28 days. At 6 months, more patients in CBT-GSC (42%)
were abstinent from binge eating compared to patients in the
family-therapy group (25%). However, this difference was no
longer significant at 12 months, and there were no differences
between the groups in frequency of vomiting at either assess-
ment point. The cost of treatment was lower for those assigned
to CBT-GSC than to family therapy.
A recent RCT compared FBT-BN with CBT adapted for
adolescents (CBT-A).44 Abstinence rates were significantly
higher for FBT-BN (39.4%) than for CBT-A (19.7%) at
end of treatment and 6-month follow-up (FBT-BN 44%,
CBT-A 25.4%), but the difference was no longer significant
at 12-month follow-up (FBT-BN 48.5%, CBT-A 32%).
More participants were hospitalized in CBT-A (21%) than
in FBT-BN (2%).
Multifamily therapy for AN
Despite evidence that FBT is an effective form of treatment
for adolescents with eating disorders,45 not all families
respond to treatment, and some need a different or more inten-
sive level of intervention. Multifamily treatment (MFT) for
eating disorders has been developed in Dresden, Germany46
and London, UK,47 and provides a promising alternative for
some families. MFT shares a conceptual focus with FBT, in
that the family is mobilized to draw on their strengths to help
the adolescent recover from the eating disorder. However,
MFT offers a more intensive experience, with five to seven
families learning from and supporting one another during an
introductory evening where families meet a “graduate fam-
ily” who shares their experience of participating in MFT. This
is followed by a 4-day intensive workshop with five to eight
follow-up sessions over the next 6–9 months, with separate
FBT sessions between follow-up visits as needed.48
Thus far, much of the data supporting the use of MFT has
consisted of uncontrolled studies.49–51 One RCT randomized
169 adolescents to either MFT (MFT-AN) or single-family
therapy, although participants randomized to MFT-AN also
received individual family meetings as needed.52 At the
end of treatment, significantly more people in the MFT-AN
group fell into good- or intermediate-outcome categories,
although this difference was no longer statistically significant
at 6-month follow-up. At the end of treatment, there were no
differences between the groups in mean percentage BMI,
eating-disorder psychopathology, depression, or self-esteem.
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 Rienecke
However, at 6-month follow-up, mean percentage BMI was
higher in the MFT-AN group.
Family-based treatment in higher
levels of care
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The efficacy of FBT has led to efforts to incorporate FBT
principles into higher levels of care, such as partial hospi-
talization programs (PHPs). While it is important to note
that FBT is an outpatient form of treatment that cannot be
replicated in higher levels of care, it is possible to remain
true to the basic tenets of the treatment approach in differ-
ent treatment settings. Hoste53 described the development
of a family-based PHP, outlining various considerations
that should be taken into account when incorporating FBT
principles, such as how to involve parents in treatment and
the role that the treatment team should take in supporting
the family. Preliminary outcome data for this program show
improvements in eating-disorder psychopathology and
For personal use only.
parental self-efficacy. Other descriptions of family-based
PHPs show promising preliminary outcomes.54,55 Although
from a clinical perspective, some patients seem to require
higher levels of care, further studies are needed to determine
whether higher levels of care are as effective as empirically
supported forms of outpatient therapy, such as FBT or CBT.
Implementation of family-based
treatment
Despite evidence supporting the efficacy of FBT and manu-
alization of the treatment for both AN and BN,16,17 in clinical
practice the treatment is often not carried out in accordance
with the manual.56 Couturier et al56 interviewed 40 thera-
pists regarding their treatment of AN, their perspectives on
evidence-based practice, and barriers and facilitating factors
related to their adoption of FBT. Although over 80% felt that
manualized FBT was well scripted and used it with their own
patients, not one therapist practiced the treatment approach
with fidelity to the manual.
Themes raised during these interviews were divided
into six categories. Interventional barriers to the use of FBT
included the time commitment required of therapists and
families, the lack of a dietitian on the treatment team, the
requirement that the therapist weighs the patient at each ses-
sion, and the family meal. Organizational factors related to
the implementation of FBT included support for the treatment
approach on the part of the organization’s clinical director or
administrator. Interpersonal factors related to reluctance to
provide evidence-based practice involved a belief that one
approach does not fit all families, and that it is not desirable
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to commit to a particular form of treatment without consider-
ing each family individually. Parental reluctance to engage
in FBT and therapist reluctance to use FBT when a parent
has an active eating disorder were listed as patient/family
barriers to implementing FBT. Systemic barriers to treat-
ment included a lack of awareness in the community about
eating disorders and treatment options. Illness factors were
also mentioned, as 68% of therapists reported that the com-
plexity of AN prohibits them from committing to one form
of treatment with full fidelity to the model. There was also
a belief that patients participating in treatment studies have
fewer comorbidities and are not representative of the general
population; therefore, using just one form of treatment would
not be desirable for more complex patients.
In another study of FBT fidelity, Kosmerly et al57 assessed
117 clinicians who reported using FBT for eating disorders.
Cluster analysis revealed that one third of clinicians used
techniques not recommended by the FBT manuals, including
individual therapy, mindfulness techniques, and motivational
work.
Three components of FBT that caused some of the most
significant discomfort for therapists in the Couturier et al
study56 were weighing the patient, the lack of a dietitian,
and the family meal. PFT38 may be a good alternative for
these clinicians, as there is no family meal and a nurse is
responsible for weighing the patient. It would also be useful
to determine whether these components of FBT are critical
to good treatment outcome. Although dismantling studies
have not been conducted, Ellison et al58 examined some of
the core objectives of FBT, including parents taking control
of eating, parents being united against the eating disorder,
parents not criticizing the patient, externalizing the illness,
and sibling support of the patient, and assessed how they
were related to treatment outcome. All objectives except for
sibling support predicted greater weight gain. A review of
the family meal in three different models of family therapy
found that firm conclusions cannot yet be drawn about the
usefulness of the family meal in treatment.59 Questions
proposed for future research include: 1) is the family meal
a necessary component of treatment?; 2) do all patients (eg,
adolescents versus young adults) benefit similarly from the
family meal?; 3) what are the components that make up an
effective family meal?; 4) how does the therapeutic context
influence the potential benefits of the family meal?; and 5) if
it is not feasible to have a family meal in session, can other
meal-oriented techniques serve the same purpose?
Without dismantling studies to identify the critical com-
ponents of FBT, it is difficult to state the consequences of
Adolescent Health, Medicine and Therapeutics 2017:8
 Dovepress
nonadherence to the treatment manual. What can be said is
that nonadherence to the treatment manual will result in the
delivery of a non-empirically supported form of treatment.
Couturier et al56 point out that it is important to determine
in these situations whether one should prescribe following
Adolescent Health, Medicine and Therapeutics downloaded from https://www.dovepress.com/ by 185.252.218.215 on 07-Aug-2018
the treatment manual as written and risk rejection of the
manual by therapists who do not feel qualified or equipped to
implement it, or whether there is room for some flexibility to
allow clinicians who are uncertain about components of the
treatment to administer it according to their comfort level.
However, it could be argued that discomfort with certain
elements of FBT could prove detrimental to treatment out-
come. For example, despite the manual clearly stating that
the patient should be weighed by the therapist prior to every
session, and that weight loss or weight gain sets the tone
for the session, over one third of therapists in the Couturier
et al56 study said that they did not weigh their FBT patients.
Although the reasons for this were not detailed in the study,
For personal use only.
Waller and Mountford60 outlined several reasons given by
therapists for not weighing their patients in the context of
CBT. These included concerns that it will ruin the therapeutic
relationship, a belief that weighing is unnecessary because
the patient weighs him/herself or is already weighed by
another professional, concern that the patient will be too
upset if weighed, stating that there is not enough time in the
session to weigh the patient, or believing that the therapist
can judge weight gain or weight loss by looking at the patient.
FBT therapists in training have also reported being fearful of
the reaction of the eating disorder. Not weighing the patient
is often done to alleviate either the patient’s anxiety or the
therapist’s anxiety. Either one can be problematic. Although
patients may become anxious when being weighed, the FBT
therapist is there to support patients and help them process
their reaction to being weighed, thereby building therapeutic
alliance and rapport.16 If the therapist avoids weighing the
patient in order to avoid making the patient anxious, this
could send a message that the therapist is not equipped to
handle the patient’s anxiety, thus creating less of a safe and
containing therapeutic environment.
Likewise, avoiding therapist anxiety could be equally
problematic. Much of an FBT therapist’s job is modeling
for parents how to interact with the eating disorder and with
their child. The therapist models an uncritical, supportive, and
compassionate stance toward the patient, along with taking
a firm, zero-tolerance approach toward eating-disordered
behavior. It will be difficult for therapists to model this firm
stance toward the eating disorder if the therapist is scared of
it. If the therapist avoids weighing the patient because of fear
Adolescent Health, Medicine and Therapeutics 2017:8
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Family-based treatment of eating disorders
of the wrath of the eating disorder, this therapist will not be
as effective in treatment.
The issue of treatment implementation is an important
one. Effective therapies do not help patients if they are not
effectively implemented. The majority of therapists in Cou-
turier et al56 requested additional training in FBT. Additional
studies are needed to assess whether the level of training in
FBT improves treatment adherence.
Adaptations to family-based
treatment
Even when practiced with full adherence to the manual,
FBT is not effective for all families. Now that the efficacy of
the treatment has been established, research can turn to the
question of what to do with families for whom FBT does not
work. In a study of early response to treatment, it was found
that 2.88% weight gain (approximately 2.2 kg) by session
4 was the strongest predictor of posttreatment remission.61
Lock et al62 examined the feasibility of an adaptive treatment
intended to enhance parental self-efficacy in families of
patients who were early nonresponders to therapy. Forty-five
patients with AN were randomized to either FBT (n=10) or
FBT with intensive parental coaching (IPC; n=35) if patients
did not gain 2.2 kg by session 4. In addition to standard FBT,
IPC included three additional sessions that focused on meal-
time coaching. In the first of these three additional sessions,
the failure to achieve adequate weight gain is presented to
the family as a crisis situation, and the family is reinvigorated
to make the behavioral changes necessary to result in weight
restoration. In the second IPC session, the therapist meets
the parents alone to identify barriers to successful weight
restoration. The third session consists of a second family
meal, after which point manualized FBT resumes.
There were no differences in attrition rates, number of ses-
sions, treatment suitability and expectancy ratings, or clinical
outcomes between the two treatment groups, indicating the
feasibility and acceptability of IPC. Mothers of patients who
responded early to treatment had higher levels of self-efficacy
than nonresponders at session 2, but after the additional IPC
sessions, parental self-efficacy scores no longer differed
between the two groups. The weight trajectories of the IPC
arm were also compared to a group of FBT nonresponders
from a different RCT (n=38).39 At baseline, the two groups’
average weight was similar. After session 4, when IPC was
introduced in the Lock et al study,62 the weight trajectories
begin to differ, and at the end of treatment patients in the
IPC arm were significantly higher in terms of weight than
patients from the Agras et al RCT. Data must be interpreted
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75
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 Rienecke
with caution, given the small sample size, but these prelimi-
nary results suggest that adaptive FBT is feasible and may
be effective in bringing about weight restoration for early
treatment nonresponders.
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Eating-disorder caregivers
Additional parental coaching may be particularly welcome,
given the stress that can accompany caring for an individual
with an eating disorder. Caregivers of people with eating
disorders experience high levels of caregiving burden and
psychological distress.63–67 Although FBT can be an intense
and challenging process for parents, parents’ experience of
FBT has not been well documented. Anecdotal accounts
suggest that it can be quite difficult.68,69 An exploration of
blogs of mothers engaged in FBT found two main themes:
the importance of social support and shifts in parenting.70
Mothers described formal support from members of their
treatment team, as well as informal support, such as support
For personal use only.
from online forum members or significant others, as being
key to their caregiving experiences. They also discussed the
shift in parenting that is often required by FBT, in the sense
that they became much more involved in their child’s life than
they were prior to the onset of the eating disorder.
Given the importance of support from others, it is worth-
while to consider ways to offer assistance to parents going
through FBT. Rhodes et al71 evaluated parent-to-parent con-
sultation for 20 families going through FBT. Ten families
received standard treatment, and ten received additional
parent-to-parent consultation. The consultation involved a
joint interview with parents new to FBT and parents who
had successfully completed treatment. Graduate parents
were asked to share their experiences of treatment and of
the weight-restoration process, and to discuss how they
facilitated the recovery of their children. Parents in parent-
to-parent consultation felt that the experience made them
feel less alone, enabled them to reflect more on family roles
and interactions, and gave them confidence that they may
be similarly successful in treatment. The consultation did
not lead to differences in percentage of ideal body weight
at the end of treatment, but it did lead to a small increase in
the rate of weight restoration.72
Online support has also been offered to parents going
through FBT.73 Thirteen caregivers participated in 15 weekly
online therapist-guided chat sessions. Participants reported
a high degree of satisfaction with the group (91.7%), and
the majority said it helped them cope with their child’s eat-
ing disorder and they would recommend the chat group to
another caregiver.
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Caregiving burden has been found to be associated with
high expressed emotion (EE).74 EE is a measure of a relative’s
attitudes and behaviors toward an ill family member across five
domains: critical comments, hostility, emotional overinvolve-
ment, positive remarks, and warmth.75 Relatives who score high
on critical comments, hostility, or emotional overinvolvement
are considered high on EE. High parental EE is associated with
poor treatment outcome in families of patients with AN,76,77
whereas parental warmth is associated with good treatment out-
come.78 Several caregiver interventions have been developed
that result in a reduction in EE.74,79,80 It would be worthwhile to
determine whether these interventions can be used to improve
treatment outcome in FBT specifically.
Conclusion
FBT is considered by some to be the first-line treatment
for adolescents with AN, and evidence is accumulating for
its use with adolescents with BN. FBT has been expanded
upon such that its principles are now included in multifamily
therapy, as well as in higher levels of care. The development
of FBT and its reliance on families as the primary agents of
change in the recovery process has significantly changed the
landscape of treatment for adolescents with eating disorders.
FBT, however, does not work for all families. Future research
is needed to identify better the families for whom FBT does
not work, determine adaptations to FBT that may increase
its efficacy for treatment nonresponders, develop ways to
improve treatment adherence among clinicians offering FBT,
and find ways to support parents during treatment better.
Acknowledgment
The author would like to thank Daniel Le Grange, PhD for
his comments on an earlier version of this manuscript.
Disclosure
Dr Rienecke receives consulting fees from the Training Insti-
tute for Child and Adolescent Eating Disorders, LLC, and
reports no other conflicts of interest in this work.
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